Emerging Technologies for Patient Engagement and Mobile Health

DoD & VA EHR Symposium

Kenyon Crowley MBA MS CPHIMS

October 1, 2013

Agenda Briefly who CHIDS is

Patient engagement and activation

Tools and technologies being deployed in pursuit of activating patients

Importance of design

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Strategy

Technology Policy

About CHIDS Center for Health Information & Decision Systems

Mission

Research, analyze, and recommend solutions to challenges surrounding the introduction and integration of information and decision technologies into the health care system

Improve the practice and delivery of health care by offering researched solutions that impact safety, quality, access, efficiency, and ROI

Partner Ecosystem

Federal and state agencies (HHS, NSF, ONC, FDA

DOD, State of MD)

Private corporations (Children’s National, J&J, CareFirst BlueCross BlueShield, Cisco, Small and Mid-Size firms)

Not-for-profits (CDT, eHealth Initiative)

Resources

Renowned scholars from multiple disciplines

Research fellows, students, partners

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Research Focus Areas

Impact and Comparative

Effectiveness of Health Information

Systems

New Models of Care (ACO, HIE,

PCMH, Care Transitions)

Healthcare Analytics (Data-

driven Health Services Insights,

Modeling, Operations)

Consumers, Quality &

Transparency, and Social Media

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Terminology “Patient activation” refers to a patient’s

knowledge, skills, ability, and willingness to manage his or her own health and care.

“Patient engagement” is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly.

“Mobile health” is the application of wireless and mobile technologies designed to improve health research, health care services and health outcomes. (Not just apps and phones)

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Potential impacts

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Source: Veroff D. et al. (2013) Health Affairs

Barriers to patient engagement Patients

Lack of health literacy

Only 12% of patients can fully understand the information given to them to make proper health decisions

Diversity of patients

Cognitive differences among patients

Extreme sensitivity to costs

Poor usability of systems

Laziness – may offend patient advocates but true in many cases – also known as the “why diet when there’s a pill for that syndrome”

Providers

Overworked physicians indicate cannot do more

Pushback from healthcare providers when they are held accountable for their patient’s actions

Insufficient provider training

Inadequate clinical information systems

70% of physicians believe health IT tools will cost more than the benefits received

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Effective Patient Engagement Strategy Shared decision-making among patients and clinicians

Provide patients with information they are able to understand

Teach patients and families how to manage their conditions

Use easy-access + easy-to-use technology for patients to engage

Have a comprehensive and historical patient record, and effective patient identity management method

Track and share the impact of activities on patient health

Get feedback from patients (surveys, focus groups, complaints)

Get patients involved in an advisory capacity

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A framework for patient engagement

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Source: Carmen K. et al. (2013) Health Affairs

Patient engagement tool: Mobile Health 85% US adults own mobile phone; 53% own

smartphone.

19% of smartphone owners have at least one health app on their phone. Exercise, diet, and weight apps are the most popular types.

One in three cell phone owners (31%) have used their phone to look for health information. (17% one year ago).

According to a March 2013 study, the market for mHealth services has now entered the commercialization phase and will reach $26 billion globally by 2017.

Market forecasted to grow at a CAGR (compound annual growth rate) of 40.4 % through 2015.

According to research by HIMSS Analytics, about half of all doctors use mobile health apps, and a quarter of consumers do.

Sources: Pew Mobile Health Survey 2012,

Mercom Report 2013, Image – Rock

Health

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Continuum of mHealth Tools

Source: Nilsen W (2012) NIH 12 10/01/2013

BioZen developed by DoD Portable, low-cost way for

patients and physicians to receive biofeedback in and out of clinic

Show real-time data from multiple body sensors

Create notes for recording session

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PE (Prolonged Exposure) Coach by DoD and VA

Support the tasks associated with prolonged exposure treatment of PTSD

Aid patients and therapists during clinical care

Streamline the professionally-guided treatment of PTSD

Interactive respiration retraining

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Life Armor for military community Browse information on 17 topics,

including sleep, depression, and post-traumatic stress

Measure and track symptoms by self-assessment

Watch videos relevant to each topic from veterans, military family members and other service members

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PTSD Coach used in VA & DoD Self-Assessment

Manage Symptoms

Find Support

Learn about PTSD

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Big issues Limited number of mobile health apps are

constructed on design principles that are theoretically derived, and little is known about their effectiveness.

How to sustain use?

Military context – Numerous device security issues

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Patient engagement tool: Secure Messaging Secure messaging offers patients, their caregivers, and/or advocates the

ability to communicate securely and electronically with health care providers.

The secure messaging framework is built around existing communication tools such as the patient portal, secure email, and the PHR.

The correspondence can be initiated by either the patient, caregiver or the provider.

Messaging may contain structured, unstructured or mixed format content.

PHRs often have a secure messaging system with security greater than standard emails.

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Air Force PHR / SM Study Air Force Medical Service implementation of a PHR with

secure messaging (SM) in Dec 2010 at Joint Base Richardson-Elmendorf in Alaska

Part I Objective: Determine factors that influence patients’ intentions to use PHR

System capabilities and benefits used: Request your next appointment Request medication renewals Receive your test and lab results Maintain a Personal Health Record (PHR) to manage your health Communicate online with your healthcare team about non-urgent symptoms Avoid unnecessary office visits and telephone calls Request a copy of your immunization record Access a large library of patient education materials Additional features have come online since 2010

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Patient Enrollment Process & System Interaction

Elmendorf

MTF Registration Desk

INTERNET

MiCare Portal

(PHR/SM)

Visit MTF to

register (show

military ID)

Updates to PHR,

messages to/from

providers

Patient registration

information Patient’s medical

information

Messages to/from

patients

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Summary of Early Findings

Positive “expectations” among patients, less so for providers

Adoption is trending up but still low

Key is personal promotion and recommendation to patients by providers

Usage is low Provider-initiated secure messaging

Identification and designation of super users

Compelling “use” stories

Overcoming provider resistance Realistic messaging and expectation management

Sufficient training of providers/staff

Workflow and business rules

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Air Force PHR / SM Study Part II Objective: Assess impact of PHR/SM on health

services utilization

Primary Care Appointments

Telephone Consults

Emergency Room Visits

Inpatient Stays

Clinical outcomes

Comparing portal users to similar non-users

Analysis in progress

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More tools: Era of the Quantified Self and Trackers

7 in 10 US adults keep track of a health indicator

60% of US adults say they track weight, diet, or exercise routine

New ways for easing burden data entry resulting in increased monitoring and support services

Popular in employer wellness initiatives

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Source: Tracking for Health (2013) Pew Internet

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Games for Health

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Definition: application of game psychology to health tasks

Why Games? Structure information such that a complex topic is

more accessible

Decades of research has provided insights about how people learn and change their health behaviors --- We can integrate this understanding into the design of highly engaging health games

Game play can influence risk perceptions, knowledge, skills, and self-confidence

Foster peer influence

Done well can be fun

Military environment – already sense of teams, competition to leverage

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Health gaming @ CHIDS w/ VA Mobile Social Engagement For Older Adults

Management of Diabetes Type II Design elements that facilitate older adults’ adoption and use of new

technology, particularly for health-related purposes

Examine the stages of behavior change from the initiation of the intervention to behavior maintenance, including the examination of intervening variables

Social and behavioral aspects of disease management

Combing provider influence with peer influence

Use of health coaches

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Social engagement research Impact of different types of rewards and

incentives

Personalization of health message content and frequency

Optimizing team structures

What educational materials improve health literacy

Personality-driven interactions

Data capture ease of input

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VA Mobile Health Family Caregiver Pilot

May 2013, Caregivers began receiving VA-loaned iPads loaded with a Suite of Apps to test over a 12-month period

Care4Caregiver

Health Advocate

Health Assessment

Journal

Notifications and Reminders

Pain Coach

PTSD Coach

RxRefill

Summary of Care

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2 graphs

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Segmenting market players

Zombies, Run! Top paid health and fitness apps #4

Key = Fun

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Mango app Health education and adherence with rewards including social

conscience type rewards

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mHealth Products versus Platforms

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Aetna CarePass API’s (subset)

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Blue Button+ API

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“All patients whose providers use Meaningful Use Stage 2 certified

technology have the ability to view, download, and securely

transmit their clinical data from their provider’s Electronic Health

Record into another product or holding place of their choice”

ONC Blue Button Co-Design Challenge

Implementation guide at http://bluebuttonplus.org/index.html

Open mHealth

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PTSD management

Type II diabetes

Health 2.0

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Data Source

Rare disease community Amyotrophic Lateral

Sclerosis (ALS)

Data collected using web crawler Patient profiles Threads and replies in

forum (reflects participation)

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Threads vs Replies

Thread

Reply

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PLM online community ALS

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Methods and Main Findings

• Exponential random graph models

• Track direction, content and reaction to information shared

in social networks

• Net inflow from urban to rural patients participating in an online

health community

• Disease prognosis, treatment experiences, emotional

Role of Design in Patient Engagement

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“Long dominant in online search,

advertising, and maps, Google has shifted

gears from utility to beauty” Fast Co. 2013

Consumer‐friendly design can make the difference between

incomprehensible and meaningful, between information overload

and health data that’s personal, relevant, and actionable. Thomas

Goetz TEDMED 2013

“A smart product is built with the human

form in mind: Rather than us having to

integrate it into our lives, the product

instinctively conforms to us.” Margaret

Rhodes

Many promising inventions flop, not because they aren't

useful, but because they aren't appealing. Kenyon

9/30/13: Apple surpasses Coke

as most valuable brand

10/01/2013 44 Source: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/

Available online at:

http://ter.ps/designguide

Designing consumer HIT applications Use methods that include high levels of user involvement and

iteration. Iterate and involve users early and often.

Use prototypes and consumer feedback based on their use of the prototype.

Most products use one or more of the following design methods: prototyping; agile development; heuristic evaluation; top-down design; lean product development; and Goals, Operations, Methods, and Selection Rules (GOMS).

Ensure the design team has medium breadth in regard to team size and the skill-sets represented.

Engage human factors experts in the design team.

“Keep it simple” - Choose a parsimonious set of features to include in the application.

Pay careful attention to user characteristics and context of use

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It takes an ecosystem…

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Innovation and Value

Customers

Employees

Scientific Community

Partners

Other Stakeholders

Thank You! Kenyon Crowley

kcrowley@rhsmith.umd.edu

@healthIT

Website: http://ter.ps/chids

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“if you want to understand a sales person’s behavior, study

their commission plan. If you want to understand a doctor’s

behavior, understand their reimbursement model.”

- Leonard Kish